Surgical Techniques

Summary This controlled study evaluated the effect of local application of norepinephrine prior to tourniquet release on blood loss, transfusion requirements and pre- and post-operative hemoglobin (Hb) levels in patients undergoing total knee arthroplasty (TKA). Of 150 consecutive patients undergoing TKA (performed by the same surgeon), 84 met the investigators’ inclusion criteria.

Summary Lin and colleagues from Taiwan present their experience with blood conservation in pediatric patients undergoing major hepatectomy. They describe their pre-, intra- and postoperative management of 14 patients. The mean age was 3.1 years (range 0.67 – 7.60 years) and the mean body weight 14 kg (range 8-26 kg). Mean intraoperative blood loss was 68 ml (range 1.25 – 13.0 ml/kg) with no intraoperative blood transfusions administered.

Summary [Remmers and Speer review some of the strategies used in the non-blood management of Jehovah’s Witness patients. They summarize Witness patients’ position on blood, blood components, blood derivatives and autologous blood options. They address, with support from the literature, approaches to managing bleeding and trauma and illustrate a proposed algorithm for the management of severe acute anemia. A brief synopsis of the surgical, anesthetic and pharmacological strategies is presented along with a table listing “oxygen therapeutics” in clinical trials.

Summary In this case report Nagarsheth and colleagues present the successful bloodless surgical and perioperative management of a patient with refractory anemia, significant comorbidities and a large uterine sarcoma with invasion of surrounding organs and vasculature. The patient’s preoperative hemoglobin was 7.1 g/dL reaching a nadir of 2.5 g/dL intraoperatively. After describing modalities utilized in this patient, the authors review the pre- intra- and postoperative strategies employed in bloodless surgery and state that all patients could potentially benefit from these strategies.

Summary Postoperative anemia after elective lumbar spinal surgery frequently requires allogenic blood transfusion, which carries well-known risks. Autologous blood obtained preoperatively lessens the need for use of allogenic blood but does not eliminate it totally. In this retrospective study, Gause and colleagues examined the effectiveness of cell-saver (CS) use intraoperatively to reduce the need for blood transfusion.

Summary Endovascular placement of stent grafts (SGs) in the management of traumatic thoracic aortic (TA) injuries is becoming the procedure of choice compared with standard operative repair (OR). This prospective, multicenter (18 institutions) study, reported by Demetriades and colleagues, assessed the safety and efficacy of the two treatment methods in 193 patients.

Summary Endovascular placement of stent grafts (SGs) in the management of traumatic thoracic aortic (TA) injuries is becoming the procedure of choice compared with standard operative repair (OR). This prospective, multicenter (18 institutions) study, reported by Demetriades and colleagues, assessed the safety and efficacy of the two treatment methods in 193 patients.

Summary The antiplatelet aspects of clopidogrel are well-known, but an association between preoperative use of the drug and postoperative bleeding has been reported in cardiac patients. Because cardiac and orthopedic patients are often of the same age group with similar comorbidities, Lavelle and colleagues examined the effect of the use of clopidogrel and the possible delay in surgical fixation, especially in patients with hip fracture, on morbidity and mortality rates.

Summary Intracerebral haemorrhage accounts for 10-15% of strokes and is associated with high mortality and severe disability in survivors. Despite its seriousness, the treatment options for intracerebral haemorrhage are limited. Measures aimed at decreasing elevated intracranial pressure are of limited effectiveness. This has stimulated an interest in attempting to improve the prognosis of intracerebral haemorrhage by addressing the haematoma directly, either removing it by surgical means or limiting its early spontaneous growth.

Summary Hemorrhage is the second most common cause of direct maternal death. Conserving and using autologous blood is an option to avoid the risks associated with allogeneic blood transfusions. Because preoperative autologous donation does not provide enough blood for obstetric hemorrhages and because the need is rarely known before delivery, this procedure is currently not recommended in obstetric patients. Intraoperative cell salvage (IOCS) may be more effective in this patient population.